eje2010_eco en valvulopatia mitral y tricuspide

7/27/2019 EJE2010_Eco en Valvulopatia Mitral y Tricuspide

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RECOMMENDATIONS

European Association of Echocardiography

recommendations for the assessment of valvularregurgitation. Part 2: mitral and tricuspid

regurgitation (native valve disease)

Patrizio Lancellotti (Chair)1*, Luis Moura2, Luc A. Pierard 1, Eustachio Agricola3,

Bogdan A. Popescu 4, Christophe Tribouilloy5, Andreas Hagendorff6, Jean-Luc Monin 7,

Luigi Badano 8, and Jose L. Zamorano 9 on behalf of the European Association of

Echocardiography

Document Reviewers: Rosa Sicari a, Alec Vahanian b, and Jos R.T.C. Roelandt c

1Department of Cardiology, ValvularDisease Clinic, University Hospital, Universite de Liege,CHU duSart Tilman, 4000Liege, Belgium;2Oporto Medical School, Porto, Portugal; 3Division

of Noninvasive Cardiology, San Raffaele Hospital, IRCCS, Milan, Italy; 4Department of Cardiology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; 5Department

of Cardiology, University Hospital of Amiens, Picardie, France; 6Department fur Innere Medizin, Kardiologie, Leipzig, Germany; 7Cardiologie/Maladie Valvulaires Cardiaques Laboratoire

dechocardiographie CHU Henri Mondor, Creteil, France; 8Department of Cardiology, University of Padova, Padova, Italy; 9University Clinic San Carlos. Madrid, Spain

aInstitute of Clinical Physiology, PISA, Italy; bHopital Bichat, Paris, France; and cDepartment of Cardiology, Thoraxcentre, Erasmus MC, Rotterdam, The Netherlands

Received 11 February 2010; accepted after revision 15 February 2010

Mitral and tricuspid are increasingly prevalent. Doppler echocardiography not only detects the presence of regurgitation but also permits to

understand mechanisms of regurgitation, quantification of its severity and repercussions. The present document aims to provide standards

for the assessment of mitral and tricuspid regurgitation.- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Keywords Valvular regurgitation Echocardiography Recommendations Mitral valve Tricuspid valve

Introduction

The second part of the recommendations on the assessment of

valvular regurgitation focuses on mitral regurgitation (MR) and tri-

cuspid regurgitation (TR). As for the first part, the present docu-

ment is based upon a consensus of experts.1 It provides cluesnot only for MR and TR quantification but also elements on the

assessment of valve anatomy and cardiac function.

Mitral regurgitation

MR is increasingly prevalent in Europe despite the reduced inci-

dence of rheumatic disease.2 The development of surgical mitral

valve repair introduced in the early seventies by Alain Carpentier

has dramatically changed the prognosis and the management of

patients presenting with severe MR. The possibility of repairing

the mitral valve imposes new responsibilities on the assessment

of MR by imaging which should provide precise information on

type and extent of anatomical lesions, mechanisms of regurgitation,

aetiology, amount of regurgitation, and reparability of the valve. It is

essential to distinguish between organic (primary) and functional(secondary) MR which radically differs in their pathophysiology,

prognosis, and management.

Anatomy and function of the mitral valveNormal mitral valve function depends on perfect function of the

complex interaction between the mitral leaflets, the subvalvular

apparatus (chordae tendineae and papillary muscles), the mitral

annulus, and the left ventricle (LV). An imperfection in any one

of these components can cause the valve to leak.3

* Corresponding author. Tel: +32 4 366 71 94, Fax: +32 4 366 71 95, Email: [email protected]

Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2010. For permissions please email: [email protected].

European Journal of Echocardiography (2010) 11, 307332

doi:10.1093/ejechocard/jeq031


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Valvular leaflets

The normal mitral valve has two leaflets (each with a thickness

about 1 mm) that are attached at their bases to the fibromuscular

ring, and by their free edges to the subvalvular apparatus. The pos-

terior leaflet has a quadrangular shape and is attached to approxi-

mately two-thirds of the annular circumference; the anterior leaflet

attaches to the remaining one-third (Figure 1). The posterior leaflet

typically has two well defined indentations which divide the leafletinto three individual scallops identified as P1, P2, and P3. The P1

scallop corresponds to the external, anterolateral portion of the

posterior leaflet, close to the anterior commissure and the left

atrium (LA) appendage. The P2 scallop is medium and more devel-

oped. The P3 scallop is internal, close to the posterior commissure

and the tricuspid annulus. The anterior leaflet has a semi-circular

shape and is in continuity with the non-coronary cusp of the

aortic valve, referred to as the intervalvular fibrosa. The free

edge of the anterior leaflet is usually continuous, without indenta-

tions. It is artificially divided into three portions A1, A2, and A3,

corresponding to the posterior scallops P1, P2, and P3. The com-

missures define a distinct area where the anterior and posterior

leaflets come together at their insertion into the annulus. Some-

times the commissures exist as well defined leaflet segments, but

more often this area is a subtle region. When the mitral valve is

closed, the line of contact between the leaflets is termed coapta-

tion line and the region of leaflet overlap is called the zone of

apposition.

By echocardiography, the presence and the extent of inadequate

tissue (e.g. calcifications), of excess leaflet tissue and the precise

localization of the leaflet lesions should be analysed. Describing

the mitral valve segmentation is particularly useful to precisely

define the anatomical lesions and the prolapsing segments in

patients with degenerative MR. For this purpose, transoesophageal

echocardiography (TEE) still remains the recommended approachin many laboratories. However, in experienced hands, functional

assessment of MR by transthoracic echocardiography (TTE) pre-

dicts accurately valve reparability. Images with both approaches

are recorded using appropriate standardized views (Figures 26).4

The short-axis view can be obtained by TTEor TEE, usingthe clas-

sical parasternal short-axis view and the transgastric view at 08. This

view permits in diastole the assessment of the six scallops and the

two commissures. In systole, the localization of prolapse may be

identified by the localization of the origin of the regurgitant jet.

With TTE, a classical apical four-chamber view is obtained and

explores the anterior leaflet, the segments A3 and A2 and the pos-

terior leaflet in its external scallop P1. With TEE, different valvularsegments are observed which depend on the position of the probe

in the oesophagus which progresses from up to down. This

permits to observe successively A1 and P1 close to the anterolat-

eral commissure, A2 and P2 and finally A3 and P3 close to the pos-

teromedial commissure (at 40 608).

Parasternal long-axis view with TTE and sagittal view at 1208

with TEE show the medium portions of the leaflets (A2 and P2).

A bi-commissural view can be obtained in the apical two-chamber

view with TTE and a view at 40608 with TEE showing the two

commissural regions and from left to right P3, A2, and P1. A two-

chamber view from the transgastric position, perpendicular to the

subvalvular apparatus permits to measure the length of the

chordae and the distances between the head of the papillary

muscle and the mitral annulus.

Real-time 3D TTE and/or TEE provide comprehensive visualiza-

tion of the different components of the mitral valve apparatus and

is probably the method of choice when available.5 Real-time 3D

TEE is particularly useful in the dialogue between the echocardio-grapher and the surgeon. Multiple views are available which permit

to precisely determine the localization and the extent of prolapse.

The en face view seen from the LA perspective is identical to the

surgical view in the operating room. This view allows to perfectly

analysing the extent of commissural fusion in rheumatic MR. The

leaflet involvement in degenerative myxomatous disease is visual-

ized by 3D echo as bulging or protrusion of one or more segments

of a single or multiple mitral valve leaflets. In addition, the presence

of chordal rupture and extension of the concomitant annular

dilation can be assessed in the same view. Preoperatively, the

measurement by 3D echo of the surface of the anterior leaflet

could help to define the size of the annular ring.

Figure 1 Real-time 3D transoesophageal echocardiography

volume rendering of the mitral valve. Left: classical transoesopha-

geal echocardiography view; right: surgical view. A1, A2, A3,

anterior mitral valve scallops; P1, P2, P3, posterior mitral valve

scallops; ANT COMM, anterolateral commissure; POST

COMM, posteromedial commissure.

Figure 2 Mitral valvular segmentation analysis with 2D trans-

oesophageal echocardiography. Views obtained at 08: (A) Five-

chamber view depicting A1 and P1, (B) four-chamber view

depicting A2 and P2; (C) downward four-chamber view depicting

A3 and P3.

P. Lancellotti et al.308


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Mitral annulus

The mitral annulus constitutes the anatomical junction between the

LV and the LA, and serves as insertion site for the leaflet tissue. It is

ovaland saddle shaped.6 Theanterior portion of themitral annulus is

attached to the fibrous trigones and is generally more developed

than the posterior annulus. Both parts of the annulus may dilate in

pathologic conditions. The anterior posterior diameter can be

measured using real-time 3D or by conventional 2D in the

parasternal long-axis view. The diameter is compared with thelength of the anterior leaflet measured in diastole. Annular dilatation

is present when the ratio annulus/anterior leaflet is .1.3 or when

the diameter is.35 mm.7 Thepresenceand extent of annularcalci-

fication is an important parameter to describe. The normal motion

and contraction of the mitral annulus also contributes to maintaining

valve competence. The normal contraction of the mitral annulus

(decrease in annular area in systole) is 25%.8

Chordae tendineae

There are three sets of chordae arising from the papillary muscles.

They are classified according to their site of insertion between the

free margin and the base of leaflets. Marginal chordae (primary


oesophageal echocardiography. (A) Two-chamber view with a

counter clock wise mechanical rotation permitting to visualizeA1, P1, and the anterolateral commissure. (B) Two-chamber

view with a clock wise mechanical rotation permitting to visualize

A3, P3, and the posteromedial commissure. (C) Bicommissural

view. (D) View at 1208 visualizing A2 and P2.


oesophageal echocardiography (TEE) and transthoracic echocar-

diography (TTE). (A) 2D TTE parasternal long-axis view depicting

A2 and P2. (B) 2D TTE parasternal short-axis view depicting eachscallop. (C) 2D TEE view at 1208 visualizing A2 and P2. (D) 2D

TEE the transgastric view at 08 depicting each scallop.

Figure 5 2D transthoracic echocardiography of parasternal

long-axis view. (A) A2 and P2. (B) A1 and P1 (tilting of the

probe toward the aortic valve). (C) A3 and P3 (tilting of the

probe toward the tricuspid (Tr) valve).


oesophageal echocardiography (B and D) and transthoracic echo-

cardiography (A and C). (A) Four-chamber view depicting A3, A2,

and P1 and (C) bicommissural view. For B and D see above.

Recommendations for the assessment of valvular regurgitation 309


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chordae) are inserted on thefree marginof theleaflets andfunctionto

prevent prolapse of theleaflet margin. Intermediatechordae (second-

arychordae)insert on theventricularsurface of theleaflets andrelieve

valvular tissue of excess tension. Often two large secondary or strut

chordae can be individualized. They may be important in preserving

ventricular shape and function. Basal chordae (tertiary chordae) are

limited to the posterior leaflet and connect the leaflet base and

mitral annulus to the papillary muscle. Additional commissuralchordae arise from each papillary muscle. Rupture, calcification,

fusion, or redundancy of the chordae can lead to regurgitation.

Papillary muscles

Because the annulus resides in the left atrioventricular furrow, and

the chordae tendineae are connected to the LV via the papillary

muscles, mitral valve function is intimately related to LV function.

There are two papillary muscles arising from the LV: the anterolat-

eral papillary muscle is often composed of one body or head, and

the posteromedial papillary muscle usually with two bodies or

heads. Rupture, fibrotic elongation or displacement of the papillary

muscles may lead to MR.

Mitral valve analysis: recommendations

(1) TTE is recommended as the first-line imaging

modality for mitral valve analysis.

(2) TEE is advocated when TTE is of non-diagnostic

value or when further diagnostic refinement is

required.

(3) 3D-TEE or TTE is reasonable to provide additional

information in patients with complex mitral valve

lesion.

(4) TEE is not indicated in patients with a good-quality

TTE except in the operating room when a mitral

valve surgery is performed.

Key point

Valve analysis should integrate the assessment of the

aetiology, the lesion process and the type of dysfunction.

The distinction between a primary and a secondary

cause of MR is mandatory. The diameter of the mitral

annulus, the leaflet involved in the disease process and

the associated valvular lesions should be carefully

described in the final report.

Aetiology and mechanism of mitralregurgitationCauses and mechanisms of MR are not synonymous. A particular

cause might produce regurgitation by different mechanisms. MR

is roughly classified as organic (primary) or functional (secondary).

Organic MR is due to intrinsic valvular disease whereas functional

MR is caused by regional and/or global LV remodelling without

structural abnormalities of the mitral valve. Causes of primary

MR include most commonly degenerative disease (Barlow, fibroe-

lastic degeneration, Marfan, Ehlers-Danlos, annular calcification),

rheumatic disease, and endocarditis. Ruptured papillary muscle

secondary to myocardial infarction defined an organic ischaemic

MR. Causes of secondary MR include ischaemic heart disease

and cardiomyopathy.

Aetiology

Degenerative mitral regurgitation

Degenerative disease is the most common aetiology of MR. Several

terms are used that should be distinguished: (i) A billowing valve isobserved when a part of the mitral valve body protrudes into the

LA; the coaptation is, however, preserved beyond the annular

plane. MR is usually mild in this condition; (ii) A floppy valve is a

morphologic abnormality with thickened leaflet (diastolic thickness

.5 mm) due to redundant tissue; (iii) Mitral valve prolapse implies

that the coaptation line is behind the annular plane. With 2D echo,

the diagnosis of prolapse should be made in the parasternal or

eventually the apical long-axis view, but not in the apical four-

chamber view, because the saddle shaped annulus may lead to

false positive diagnosis (Figure 7). The most common phenotype

of mitral prolapse is diffuse myxomatous degeneration (Barlows

disease; Figures 8 and 9); (iv) Flail leaflet: this term is used when

the free edge of a leaflet is completely reversed in the LA (the

leaflet tip is directed towards the LA while in prolapse it is directed

towards the LV). Flail leaflet is usually a consequence of ruptured

chordae (degenerative MR or infective endocarditis). It affects

more frequently the posterior leaflet (.70% of cases) and is

usually associated with severe MR.

Rheumatic mitral regurgitation

Rheumatic MR is characterized by variable thickening of the leaflets

especially at the level of their free edge. Fibrosis of the chordae is

frequent, especially of those attached to the posterior valve

explaining the rigidity and reduced motion of the posterior

leaflet in diastole. In some patients, the posterior leaflet remains

Figure 7 (A) In normal mitral valve, the coaptation (red point)

occurs beyond the mitral annular plane (line); (B) billowing mitral

valve is observed when a part of the mitral valve body protrudes

into the left atrium (arrow); (C and D) mitral valve prolapse is

defined as abnormal systolic displacement of one (C: posterior

prolapse) or both leaflets into the left atrium below the

annular (D: bileaflet prolapse); (E) flail of the anterior leaflet

(arrow).



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in a semi-open position throughout the cardiac cycle and the

motion of the anterior leaflet in systole produces a false aspect

of prolapse.

Functional mitral regurgitation

Functional MR broadly denotes abnormal function of normal leaf-

lets in the context of impaired ventricular function resulting from

ischaemic heart disease or dilated cardiomyopathy.9 It results

from an imbalance between tethering forcesannular dilatation,

LV dilatation, papillary muscles displacement, LV sphericityand

closing forcesreduction of LV contractility, global LV dyssyn-

chrony, papillary muscle dyssynchrony, altered mitral systolicannular contraction. Chronic functional ischaemic MR results, in

95% of the cases, from a type IIIb (systolic restriction of leaflet

motion) dysfunction. The restrictive motion occurs essentially

during systole and is most frequent in patients with previous pos-

terior infarction (asymmetric pattern; Figure 10).10 In this setting,

the traction on the anterior leaflet by secondary chordae can

induce the so called seagull sign. In patients with idiopathic cardi-

omyopathy or with both anterior and inferior infarctions, both leaf-

lets exhibit a reduced systolic motion leading to incomplete

coaptation (symmetric pattern; Figure 11). Rarely, in ischaemic

Figure 10 Ischaemic mitral regurgitation with a predominant

posterior leaflet restriction (arrows) leading to an asymmetric

tenting pattern. The restriction on the anterior leaflet due exces-

sive stretching by the strut chordate provides the typical seagull

sign (white arrow). The colour jet is originating centrally but is

directed laterally toward the lateral wall of the left atrium.

Figure 11 Ischaemic mitral regurgitation with a bileaflet

restriction (arrows) leading to a symmetric tenting pattern. The

colour jet is originating and directed centrally into the left atrium.

Figure 9 3D-transoesophageal echocardiography rendering of

the mitral valve. (A) Posteromedial (POST-COMM) commissure

prolapse; (B) anterolateral (ANT-COMM) commissure prolapse;

(C) P2 prolapse; (D) flail of P3.

Figure 8 Example of severe Barlows disease with redundant

and thickened mitral valve.



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MR, the mechanism of MR is related to fibrosis and elongation of

the papillary muscle (Figure 12). On echo, the LV is dilated and

more spherical. The annulus is also usually dilated, becomes

more circular with lack of dynamic systolic contraction. A

number of anatomic measurements can be made that reflect the

pathophysiology of functional MR, including global and regional

LV remodelling and the severity of altered geometry of the

mitral valve apparatus (tenting area and coaptation distance;

Figure 13).11 The location and extent of regional and global LV dys-

function are easily assessed in the classical views (parasternal long-

axis and short-axis and apical two, three, and four chamber views).

Thin (diastolic thickness ,5.5 mm) and hyper-echogenic ventricu-

lar segments usually imply the presence of transmural infarction.

Global LV remodelling is quantified by the measurements of LVvolumes and the calculation of the LV sphericity index. Regional

remodelling is quantified by the posterior and lateral displacements

of one or both papillary muscles. The tenting area is measured in

mid-systole as the area between the mitral annulus and the mitral

leaflets body. The apical displacement of the coaptation point

(coaptation distance) represents the distance between the mitral

annular plane and the point of coaptation.

Mechanisms of mitral regurgitation

Precise determination of the mechanism of MR is an essential com-

ponent of the echocardiographic examination, in particular when

mitral valve repair is considered. The Capentiers functional classi-fication is often used: (i) Type I: MR is determined by leaflet per-

foration (infective endocarditis) or more frequently by annular

dilatation; (ii) Type II: Excessive leaflet mobility accompanied by

displacement of the free edge of one or both leaflets beyond the

Figure 12 Ischaemic mitral regurgitation due to ischaemic

elongation of the posteromedial papillary muscle (red arrow).

Yellow arrow: anterior leaflet prolapse.

Figure 13 Echo morphologic parameters that are measured in ischeamic mitral regurgitation. (A) Global left ventricle remodelling [diameter,

left ventricle (LV) volumes, sphericity index (SI L/1; L, major axis; 1, minor axis)]. (B) Local LV remodelling (1, apical displacement of the

posteromedial papillary muscle; 2, second order chordate; 3, interpapillary muscle distance). (C) Mitral valve deformation (1, systolic tenting

area (TA); 2, coaptation distance (CD); 3, posterolateral angle (PLA)).



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mitral annular plane (mitral valve prolapse); (iii) Type III: The type

III is subdivided into type IIIa implying restricted leaflet motion

during both diastole and systole due to shortening of the

chordae and/or leaflet thickening such as in rheumatic disease,

and type IIIb when leaflet motion is restricted only during systole

(Figure 14).

Predictors of successful valve repair

Several echocardiographic parameters can help to identify patients

at risk of treatment failure. In organic MR, some predictors of

unsuccessful repair have been reported: the presence of a large

central regurgitant jet, severe annular dilatation (.50 mm), invol-

vement of3 scallops especially if the anterior leaflet is involved,

and extensive valve calcification (Table 1).12 Moreover, lack of valve

tissue is also an important predictor of unsuccessful repair both in

rheumatic valve disease and in patients who have had infective

endocarditis with large valve perforation.

In functional ischaemic MR, per-operatively (TEE), patients with a

mitral diastolic annulus diameter 37 mm, a systolic tenting area

1.6 cm2 and a severe functional ischaemic MR could have a 50%

probability of failure during follow-up.13 Pre-operatively (TTE), a coap-

tation distance.1 cm, a systolic tenting area .2.5 cm2, a posterior

leaflet angle .458 (indicating a high posterior leaflet restriction), acentral regurgitant jet (indicating a severe restriction of both leaflets

in patients with severe functional ischaemic MR), the presence of

complex jets originating centrally and posteromedially, and a severe

LV enlargement (low likelihood of reverse LV remodelling after

repair and poor late outcome) increase the risk of mitral valve repair

failure.Taking these parameters altogether could reduce the frequency

of postoperative functional ischaemic MR recurrence (Table 2).11

Key point

The echocardiographic report should provide clues on

the likelihood of valve repair.

Risk of systolic anterior motion after mitral valve surgery

The development of systolic anterior motion (SAM) of the mitral

valve with LV outflow tract obstruction after mitral valve repair

can lead to severe post-operative haemodynamic instability.

Factors predisposing patients to SAM are the presence of a myx-

omatous mitral valve with redundant leaflets (excessive anterior

leaflet tissue), a non-dilated hyperdynamic LV, and a short distance

between the mitral valve coaptation point and the ventricular

septum after repair.

Assessment of mitral regurgitationseverityColour flow Doppler

Colour flow imagingColour flow imaging, although less accurate, is the most common

way to assess MR severity.14 The general assumption is that as the

severity of the MR increases, the size and the extent of the jet

into the LA also increases. Theoretically, larger colour jets that

extend deep into the LA represent more MR than small thin jets

that appear just beyond the mitral leaflets. However, the relation

between jet size and MR severity presents a large range of variability

because in addition to regurgitation severity, the colour flow display

Figure 14 Mechanisms of mitral regurgitation according to the

Capentiers functional classification.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Table 1 Probability of successful mitral valve repair in organic mitral regurgitation based on echo findings

Aetiology Dysfunction Calcification Mitral annulus dilatation Probability of repair

Degenerative II: Localized prolapse (P2 and/or A2) No/Localized Mild/Moderate Feasible

Ischaemic/Functional I or IIIb No Moderate Feasible

Barlow II: Extensive prolapse (3 scallops,

posterior commissure)

Localized (annulus) Moderate Difficult

Rheumatic IIIa but pliable anterior leaflet Localized Moderate Difficult

Severe Barlow II: Extensive prolapse (3 scallops,

anterior commissure)

Extensive (annulus+ leaflets) Severe Unlikely

Endocarditis II: Prolapse but destructive lesions No No/Mild Unlikely

Rheumatic IIIa but stiff anterior leaflet Extensive (annulus+ leaflets) Moderate/Severe Unlikely

Ischaemic/Functional I IIb but severe valvular deformation No No or Severe Unlikely



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depends on many technical and haemodynamic factors. For a similar

severity, patients with increased LA pressure or with eccentric jets

that hug the LA wall or in whom the LA is enlarged may exhibit

smaller jets area than those with normal LA pressure and size or

with central jets (Figure 15).15 In acute MR, even centrally directed

jets may be misleadingly small. Furthermore, as this method is a

sourceof many errors, it is not recommended to assess MR severity.

Nevertheless, the detection of a large eccentric jet adhering, swirlingand reaching the posterior wall of the LA is in favour of significant

MR. Conversely, small thin jets that appear just beyond the mitral

leaflets usually indicate mild MR.

Key point

The colour flow area of the regurgitant jet is not rec-

ommended to quantify the severity of MR. The colour

flow imaging should only be used for diagnosing MR.

A more quantitative approach is required when more

than a small central MR jet is observed.

Vena contracta width

The vena contracta is the area of the jet as it leaves the regurgitant

orifice; it reflects thus the regurgitant orifice area.1618 The vena

contracta is typically imaged in a view perpendicular to the com-missural line (e.g. the parasternal long-axis or the apical four-

chamber view) using a careful probe angulation to optimize the

flow image, an adapted Nyquist limit (colour Doppler scale)

(4070 cm/s) to perfectly identify the neck or narrowest portion

of the jet and the narrowest Doppler colour sector scan

coupled with the zoom mode to improve resolution and measure-

ment accuracy (Figure 16). Averaging measurements over at least

two to three beats and using two orthogonal planes whenever

possible is recommended. A vena contracta ,3 mm indicates

mild MR whereas a width 7 mm defines severe MR. Intermediate

values are not accurate at distinguishing moderate from mild or

severe MR (large overlap); they require the use of another

method for confirmation.

The concept of vena contracta is based on the assumption that

the regurgitant orifice is almost circular. The orifice is roughly cir-

cular in organic MR; although in functional MR, it appears to be

rather elongated along the mitral coaptation line and non-

circular.19,20 Thus, the vena contracta could appear at the same

time narrow in four-chamber view and broad in two-chamber

view. Moreover, conventional 2D colour Doppler imaging does

not provide appropriate orientation of 2D scan planes to obtain

an accurate cross-sectional view of the vena contracta. The vena

contracta can be classically well identified in both central and

eccentric jets. In case of multiple MR jets, the respective widths

of the vena contracta are not additive. Such characteristics maybe better appreciated and measured on 3D echocardiography. In

functional MR, a mean vena contracta width (four- and two-

chamber views) has been shown to be better correlated with

the 3D vena contracta. A mean value .8 mm on 2D echo

(Figure 17) has been reported to define severe MR for all

Figure 15 Visual assessment of mitral regurgitant jet using

colour-flow imaging. Examples of two patients with severe

mitral regurgitation. (A) Large central jet. (B) Large eccentric jet

with a clear Coanda effect. CV, four-chamber view.

Figure 16 Semi-quantitative assessment of mitral regurgitation

severity using the vena contracta width (VC). The three com-

ponents of the regurgitant jet (flow convergence zone, vena con-

tracta, jet turbulence) are obtained. CV, chamber view; PT-LAX,

parasternal long-axis view.

Table 2 Unfavourable TTE characteristics for mitral

valve repair in functional mitral regurgitation11

Mitral valve deformation

Coaptation distance 1 cm

Tenting area .2.5 3 cm2

Complex jets

Posterolateral angle .458

Local LV remodelling

Interpapillary muscle distance .20 mm

Posterior papillary-fibrosa distance .40 mm

Lateral wall motion abnormality

Global LV remodelling

EDD . 65 mm, ESD. 51 mm (ESV . 140 mL)

Systolic sphericity index .0.7

EDD, end-diastolic diameter; ESD, end-systolic diameter; ESV, end-systolic

volume; LV, left ventricle.



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aetiologies of MR including functional MR.2123 These data need,

however, to be confirmed in further studies.

Key point

When feasible, the measurement of vena contracta is

recommended to quantify MR. Intermediate vena con-

tracta values (3 7 mm) need confirmation by a more

quantitative method, when feasible. The vena contracta

can often be obtained in eccentric jet. In case of multiple

jets, the respective values of the vena contracta width are

not additive. The assessment of the vena contracta by 3D

echo is still reserved for research purposes.

The flow convergence method

Over the last few years, the flow convergence method has gained

interest. It is now by far the most recommended quantitative

approach whenever feasible.24 The apical four-chamber view is clas-

sically recommended for optimal visualization of the proximal isove-

locity surface area (PISA). However, the parasternal long- or

short-axis view is often useful for visualization of the PISA in case

of anterior mitral valve prolapse. The area of interest is optimized

by lowering imaging depth and reducing the Nyquist limit to

1540 cm/s. The radius of the PISA is measured at mid-systole

using the first aliasing. Regurgitant volume (R Vol) and effective

regurgitant orifice area (EROA) are obtained using the standard

formula (Figure 18). Qualitatively, the presence of flow convergence

at a Nyquist limit of 5060 cm/s should alert to the presence ofsignificant MR. Grading of severity of organic MR classifies regurgita-

tion as mild, moderate or severe, and sub-classifies the moderate

regurgitation group into mild-to-moderate (EROA of 2029 mm

or a R Vol of 3044 mL) and moderate-to-severe (EROA of

3039 mm2 or a R Vol of 4559 mL). Quantitatively, organic MR

Figure 17 Semi-quantitative assessment of mitral regurgitation

(MR) severity using the vena contracta width (VC) obtained from

the apical four-chamber and two-chamber views (CV) in a patient

with ischaemic functional MR. The mean vena contracta is calcu-

lated [(6 + 10)/2 8 mm].

Figure 18 Quantitative assessment of mitral regurgitation (MR) severity using the proximal isovelocity surface area method. Stepwise analysis

of MR: (A) Apical four-chamber view (CV); (B) colour-flow display; (C) zoom of the selected zone; (D) downward shift of zero baseline to

obtain an hemispheric proximal isovelocity surface area; (E) measure of the proximal isovelocity surface area radius using the first aliasing;

(F) continuous wave Doppler of MR jet allowing calculation the effective regurgitant orifice area (EROA) and regurgitant volume (R Vol).

TVI, time-velocity integral.



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is considered severe if EROA is 40 mm2 and R Vol 60 mL. In

ischaemic MR, the thresholds of severity, which are of prognostic

value, are 20 mm2 and 30 mL, respectively.25 EROA is the most

robust parameter as it represents a marker of lesion severity. A

large EROA can lead to large regurgitant kinetic energy (large R

Vol) but also to potential energy, with low R Vol but high LA

pressure.

As mentioned in the first part of the EAE recommendations onthe assessment of valvular regurgitation, the PISA method faces

several advantages and limitations (Figures 1921).1,26 Colour

M-mode is important to assess the variation of the PISA during

systole (Figure 22). The PISA radius is most frequently constant

in patients with rheumatic MR. It frequently increases progressively

with a maximum during the second half of systole in patients with

mitral valve prolapse. In the presence of functional MR, there is a

dynamic variation of regurgitant orifice area with early and late sys-

tolic peaks and a mid-systolic decrease. These changes reflects the

phasic variation in transmitral pressure that acts to close the mitral

leaflets more effectively when pressure reaches its peak in mid-systole.27 The PISA method is based on the assumption of hemi-

spheric symmetry of the velocity distribution proximal to the

regurgitant lesion, which may not hold for eccentric jets, multiple

jets, or complex or elliptical regurgitant orifices. Practically, the

geometry of the PISA varies, depending on the shape of the

orifice and mitral valve leaflets surrounding the orifice. In func-

tional MR, the PISA might look like an ellipsoidal shape and two

separate MR jets originating from the medial and lateral sides of

the coaptation line can be observed on 2D echo. When the

shape of the flow convergence zone is not a hemisphere, the

PISA method may underestimate the degree of functional MR, par-

ticularly when the ratio of long-axis length to short-axis length of

the 3D regurgitant orifice is .1.5.28 When the EROA is calculated

with the hemispheric assumption (using the vertical PISA), the

horizontal length of PISA is ignored. In organic MR, the shape of

the PISA is rounder, which minimizes the risk of EROA underesti-

mation (Figure 23). These findings could explain why the threshold

used to define a severe functional MR is inferior to that used for

organic MR. Careful consideration of the 3D geometry of PISA

may be of interest in evaluating the severity of functional MR.

The best 3D echo method to quantitate MR severity is still not

defined.

Figure 19 To avoid the underestimation of the regurgitant

volume the ratio of the aliasing velocity (Va) to peak orifice vel-

ocity (vel) is maintained ,10%.

Figure 20 Example of eccentric mitral regurgitation that can still be perfectly assessed by using the proximal isovelocity surface area method.



11/26

Key point

When feasible, the PISA method is highly rec-

ommended to quantitate the severity of MR. It can be

used in both central and eccentric jets. An EROA

40 mm2 or a R Vol 60 mL indicates severe organic MR.In functional ischaemic MR, an EROA 20 mm2 o r a R Vol 30 mL identifies a subset of patients at increasedrisk of cardiovascular events.

Pulsed Doppler

Doppler volumetric method

Quantitative PW Doppler method can be used as an additive oralternative method, especially when the PISA and the vena con-

tracta are not accurate or not applicable. This approach is time

consuming and is associated with several drawbacks.1,29

Key point

The Doppler volumetric method is a time-consuming

approach that is not recommended as a first line

method to quantify MR severity.

Anterograde velocity of mitral inflow: mitral to aortic time-velocity

integral (TVI) ratio

In the absence of mitral stenosis, the increase is transmitral flow

that occurs with increasing MR severity can be detected ashigher flow velocities during early diastolic filling (increased E vel-

ocity). In the absence of mitral stenosis, a peakE velocity .1.5 m/s

suggests severe MR. Conversely, a dominant A wave (atrial con-

traction) basically excludes severe MR. These patterns are more

applicable in patients older than 50 years old or in conditions of

impaired myocardial relaxation. The pulsed Doppler mitral to

aortic TVI ratio is also used as an easily measured index for the

quantification of isolated pure organic MR. Mitral inflow Doppler

tracings are obtained at the mitral leaflet tips and aortic flow at

the annulus level in the apical four-chamber view. A TVI ratio

Figure 22 Four examples of flow convergence zone changes during systole using colour M-Mode. (A and B) Functional mitral regurgitation

(A: early and late peaks and mid-systolic decreases; B: early systolic peak), (C) rheumatic mitral regurgitation with a end-systolic decrease in flow

convergence zone, (D) M mitral valve prolaspe (late systolic enhancement).

Figure 21 (A) Example of a flat flow convergence zone; (B)

presence of two jets; (C and D) distorted and constrained flow

convergence zone by the lateral myocardial wall.



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.1.4 strongly suggests severe MR whereas a TVI ratio ,1 is in

favour of mild MR (Figure 24).30

Pulmonary venous flow

Pulsed Doppler evaluation of pulmonary venous flow pattern

is another aid for grading the severity of MR (Figure 25).31

In normal individuals, a positive systolic wave (S) followed

by a smaller diastolic wave (D) is classically seen in the

absence of diastolic dysfunction. With increasing severity of

MR, there is a decrease of the S wave velocity. In severe

MR, the S wave becomes frankly reversed if the jet is directed

into the sampled vein. As unilateral pulmonary flow reversal

can occur at the site of eccentric MR jets, sampling through

all pulmonary veins is recommended, especially during trans-oesophageal echocardiography. Although, evaluation of right

upper pulmonary flow can often be obtained using TTE,

evaluation is best using TEE with the pulse Doppler sample

placed about 1 cm deep into the pulmonary vein. Atrial fibril-

lation and elevated LA pressure from any cause can blunt

forward systolic pulmonary vein flow. Therefore, blunting of

pulmonary venous flow lacks of specificity for the diagnosis

of severe MR.

Key point

Both the pulsed Doppler mitral to aortic TVI ratio and

the systolic pulmonary flow reversal are specific for severe

MR. They represent the strongest additional parameters

for evaluating MR severity.

Figure 24 Three examples of various degrees of mitral regurgitation (MR), mild (A), moderate (B), and severe (C) are provided. The regur-

gitant jet as well as the mitral E wave velocity increase with the severity of MR. In severe MR, the continuous wave Doppler signal of the regur-

gitant jet is truncated, triangular and intense. Notching of the continuous wave envelope (cut-off sign) can occur in severe MR. TVI, time-velocity

integral.

Figure 23 3D shape of the flow convergence in functional (A)

(hemielliptic) and organic mitral regurgitation (B) (hemispheric).



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Continuous wave Doppler of mitral regurgitation jet

Peak MR jet velocities by CW Doppler typically range between 4and 6 m/s. This reflects the high systolic pressure gradient between

the LV and LA. The velocity itself does not provide useful infor-

mation about the severity of MR. Conversely, the signal intensity

(jet density) of the CW envelope of the MR jet can be a qualitative

guide to MR severity. A dense MR signal with a full envelope indi-

cates more severe MR than a faint signal. The CW Doppler envel-

ope may be truncated (notch) with a triangular contour and an

early peak velocity (blunt). This indicates elevated LA pressure

or a prominent regurgitant pressure wave in the LA due to

severe MR. In eccentric MR, it may be difficult to record the full

CW envelope of the jet because of its eccentricity, while the

signal intensity shows dense features.

Key point

The CW Doppler density of the MR jet is a qualitative

parameter of MR severity.

Consequences of mitral regurgitationThe presence of severe MR has significant haemodynamic effects,

primarily on the LV and LA.

Left ventricle size and function

The LV dimensions and ejection fraction reflect the hearts ability to

adapt to increased volume load. In the chronic compensated phase

(the patient could be asymptomatic), the forward stroke volume ismaintained through an increase in LV ejection fraction. Such patients

typically have LV ejection fraction.65%. Even in theacute stage,the

LVejectionfraction increasein response to theincreased preload. In

the chronic decompensated phase (the patient could still be asymp-

tomatic or may fail to recognize deterioration in clinical status), the

forward stroke volume decreases and the LA pressure increases sig-

nificantly. The LV contractility can thus decrease silently and irrever-

sibly. However, the LV ejection fraction may still be in the low

normal range despite the presence of significant muscle dysfunction.

In the current guidelines, surgery is recommended in asymptomatic

patients with severe organic MR when the LV ejection fraction is

60%. The end-systolic diameter is less preload dependent than

the ejection fraction and could in some cases be more appropriate

to monitor global LV function. An end-systolic diameter.45 mm

(or40 mm or.22 mm/m2, AHA/ACC), also indicates the need

for mitral valve surgery in these patients.2,32,33 New parameters

are currently available for a better assessment of LV function. A sys-

tolic tissue Doppler velocity measured at the lateral annulus

,10.5 cm/s has been shown to identify subclinical LV dysfunction

and to predict post-operative LV dysfunction in patients with asymp-tomatic organic MR.34 Strain imaging allows a more accurate esti-

mation of myocardial contractility than tissue Doppler velocities.

It is not influenced by translation or pathologic tethering to adjacent

myocardial segments, which affect myocardial velocity measure-

ments. In MR, strain has been shown to decrease even before LV

end-systolic diameter exceeds 45 mm.35 A resting longitudinal

strain rate value ,1.07/s (average of 12 basal and mid segments)

is associated with the absence of contractile reserve during exercise

and thus with subclinical latent LV dysfunction.36 By using the

2D-speckle tracking imaging (an angle independent method), a

global longitudinal strain ,18.1% has been associated with post-

operative LV dysfunction.37 Practically, the incremental value of

tissue Doppler and strain imaging for identifying latent LV dysfunc-

tion remains to be determined.

Left atrial size and pulmonary pressures

TheLA dilatesin response to chronic volume andpressure overload.A

normalsizedLA is notnormallyassociated with significant MR unlessit

is acute, in which case the valve appearance is likely to be grossly

abnormal. LA remodelling (diameter.4050 mm or LA volume

index .40 mL/m2) may predict onset of atrial fibrillation and poor

prognosis in patients with organic MR.38 Conversely, MV repair

leads to LA reverse remodelling, the extent of whichis related to pre-

operative LA size and to procedural success.39 The excess regurgitant

blood entering in the LA may induce acutely or chronically a progress-ive rise in pulmonary pressure. The presence of TR even if it is mild,

permits the estimation of systolic pulmonary arterial pressure.

Recommendation for mitral valve repair is a class IIa when pulmonary

arterial systolic pressure is .50 mm Hg at rest.

Key point

When MR is more than mild MR, providing the LV diam-

eters, volumes and ejection fraction as well as the LA

dimensions (preferably LA volume) and the pulmonary

arterial systolic pressure in the final echocardiographic

report is mandatory.1 The assessment of regional myocar-

dial function (systolic myocardial velocities, strain, strain

rate) is reasonable particularly in asymptomatic patientswith severe organic MR and borderline values in terms

of LV ejection fraction (6065%) or LV end-systolic diam-

eter (closed to 40 mm or 22 mm/m2).

Role of exercise echocardiographyOrganic mitral regurgitation

In asymptomatic patients with severe MR, exercise stress echocardio-

graphy may help identify patients with unrecognized symptoms or

subclinical latent LV dysfunction. Moreover, exercise echocardiogra-

phy may also be helpful in patients with equivocal symptoms out of

proportion of MR severity at rest. Worsening of MR severity, a

marked increase in pulmonary arterial pressure, impaired exercise

Figure 25 (A) Normal pulmonary vein flow pattern; (B) blunt

forward systolic pulmonary vein flow in a patient with moderate

mitral regurgitation (MR); (C) reversed systolic pulmonary flow in

a patient with severe MR. S, systolic wave; D, diastolic wave.



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capacity, and the occurrence of symptoms during exercise echocar-

diography can be useful findings to identify a subset of patients at

higher risk who may benefit from early surgery.40 A pulmonary

artery systolic pressure .60 mmHg during exercise has been

suggested as a threshold value above which asymptomatic patients

with severe MR might be referred for surgical valve repair. Although

the inclusion of pulmonary hypertension as an indication for valve

surgery in the guidelines seems logical from a pathophysiologicalstandpoint, there are, surprisingly, very limited outcome data to

support this recommendation as well as the selected cut-off value

for pulmonary arterial pressure (.60 mmHg, ACC/AHA). The appli-

cation of stress echocardiography in organic MR is rated as a class IIa

recommendation with level of evidence C in the ACC/AHA guide-

lines. To note, the place of stress echocardiography in this setting is

not defined in the ESC recommendations, probably because of lack

of robust data. An inability to increase the LV ejection fraction

(,4%) or reduce the end-systolic volume after treadmill exercise

has been shown to reflect the presence of an impaired contractile

reserve, and to be reliable early markers for progressive deterioration

in myocardial contractility.36 The absence of contractile reserve has

also been associated with post-operative morbidity. A small change

in 2D-speckle global longitudinal strain at exercise (,1.9%) has also

been correlated with post-operative LV dysfunction. The incremental

value of these cut-off values remains to be confirmed.37

Key point

Exercise echocardiography is useful in asymptomatic

patients with severe organic MR and borderline values of

LV ejection fraction (6065%) or LV end-systolic diameter

(closed to 40 mm or 22 mm/m2). The absence of contrac-

tile reserve could identify patients at increased risk of car-

diovascular events. Moreover, exercise echocardiography

may also be helpful in patients with equivocal symptoms

out of proportion of MR severity at rest.

Functional mitral regurgitation

Quantitation of functional MR during exercise is feasible using the

PISA method.41 The degree of MR at rest is unrelated to

exercise-induced changes in ERO.8 Dynamic MR is strongly

related to exercise-induced changes in systolic tenting area and

to intermittent changes in LV synchronicity. Large exercise-induced

increases in functional ischaemic MR (EROA 13 mm2) are

associated with dyspnea or acute pulmonary oedema.42,43

Dynamic MR also predicts mortality and hospitalization for heart

failure. Exercise stress echocardiography may thus unmask haemo-

dynamically significant MR in patients with functional ischaemic LVsystolic dysfunction and only mild to moderate MR at rest, and in

doing so identify patients at higher risk for heart failure and death.

Exercise Doppler echocardiography might provide useful infor-

mation in the following patients with ischaemic MR: (i) those

with exertional dyspnea out of proportion to the severity of

resting LV dysfunction or MR; (ii) those in whom acute pulmonary

edema occurs without an obvious cause; and (iii) those with mod-

erate MR before surgical revascularization.

Key point

Exercise echocardiography is useful in patients with

functional ischaemic MR and chronic LV systolic dysfunc-

tion to unmask the dynamic behaviour of MR. Patients

with an increase in EROA by 13 mm2 are patients atincreased risk of cardiovascular events. In these patients,

exercise echocardiography also helps to identify the pres-

ence and extent of viable myocardium at jeopardy.

Integrating indices of severityEchocardiographic assessment of MR includes integration of data

from 2D/3D imaging of the valve and ventricle as well asDoppler measures of regurgitation severity (Table 3). Effort

should be made to quantify the degree of regurgitation, except

in the presence of mild or less MR. Both the vena contracta

width and the PISA method are recommended. Adjunctive par-

ameters help to consolidate about the severity of MR and

should be widely used particularly when there is discordance

between the quantified degree of MR and the clinical context.

For instance, a modest regurgitant volume reflects severe MR

when it develops acutely into a small, non-compliant LA and it

may cause pulmonary congestion and systemic hypotension.

Advantages and limitations of the various echo Doppler par-

ameters used in assessing MR severity are detailed in Table 4.

Recommended follow-upModerate organic MR requires clinical examination every year and

an echocardiogram every 2 years. In patients with severe organic

MR, clinical assessment is needed every 6 months and an echocar-

diogram every 1 year. If the ejection fraction is 6065% and/or if

end-systolic diameter is closed to 40 or 22 mm/m2, the echocar-

diogram should be performed every 6 months.1 Progression of

MR severity is frequent with important individual differences.

The average yearly increase in regurgitant volume is 7.5 mL and

5.9 mm2 in EROA.44 In addition, the progression of other par-

ameters need to be assessed: the increase in annular size, the

development of a flail leaflet, the evolution of LV end-systolic

dimension, LV ejection fraction, LA area or volume, pulmonary sys-

tolic arterial pressure, exercise capacity, and occurrence of atrial

arrhythmias.

Tricuspid regurgitation

TR is a common insufficiency. Since it is mostly asymptomatic and

not easily audible on physical examination, it is frequently only

diagnosed by echocardiography performed for another indication.

Although a mild degree of TR is frequent and benign, moderate

and severe TR are associated with poor prognosis.

Anatomy and function of the tricuspidvalveThe tricuspid valve complex is similar to the mitral valve but has

greater variability. It consists of the annulus, leaflets, right ventricle

(RV), papillary muscles, and chordae tendineae. The tricuspid valve

lays between the right atrium (RA) and the RV and is placed in a

slightly more apical position than the mitral valve.45

The tricuspid valve has three leaflets of unequal size: the

anterior leaflet is usually the largest and extends from the infundi-

bula region anteriorly to the inferolateral wall posteriorly; the

septal leaflet extends from the interventricular septum to the



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posterior ventricular border; the posterior leaflet attaches along

the posterior margin of the annulus from the septum to the infer-olateral wall. The insertion of the septal leaflet of the tricuspid

valve is characteristically apical relative to the septal insertion of

the anterior mitral leaflet. The three main TTE views allowing

the tricuspid valve visualization are the parasternal, the apical four-

chamber and the subcostal views. Parasternal long-axis view of the

RV inflow is obtained by tilting the probe inferomedially and rotat-

ing it slightly clockwise from the parasternal long-axis view of the

LV. This incidence reveals the anterior tricuspid leaflet (near the

aortic valve) and the posterior tricuspid leaflet. Parasternal short-

axis view, at the level of the aortic valve, apical four-chamber view

and subcostal four-chamber view visualize the septal and the

anterior tricuspid leaflets (Figure 26). TEE for the tricuspid valveis possible with the four-chamber view at 08 in the basal transoe-

sophageal and oesogastric junction planes. TEE is of interest for the

diagnosis of endocarditis when suspected. It is particularly essential

to diagnose venous catheters and pacemakers lead infection

because TTE is often non diagnostic in these settings. TEE can

also help accurate tricuspid valve chordae visualization when trau-

matic rupture is suspected with TTE. However, it is rarely possible

to visualize by 2D echo the three leaflets simultaneously. Real-time

3D TTE is now routinely available and allows, with its unique capa-

bility of obtaining a short-axis plane of the tricuspid valve, simul-

taneous visualization of the three leaflets moving during the

cardiac cycle and their attachment to the tricuspid annulus.46 3D

echo supplements 2D echo and TEE with detailed images of the

morphology of the valve including leaflets size and thickness,annulus shape and size, myocardial walls, and their anatomic

relationships.

The tricuspid annulus, providing a firm support for the tricuspid

leaflets insertion, is slightly larger than the mitral valve annulus.

The tricuspid annulus shows a non-planar structure with an elliptical

saddle-shaped pattern, having two high points (oriented superiorly

towards the RA) and two low points (oriented inferiorly toward

the RV that is best seen in mid-systole). Normal tricuspid valve

annulus diameter in adults is 28+5 mm in the four-chamber

view. Significant tricuspid annular dilatation is defined by a diastolic

diameter of.21 mm/m2 (.35 mm). A correlation exists between

tricuspid annulus diameter and TR severity: a systolic tricuspidannulus diameter.3.2 cm or a diastolic tricuspid annulus diameter

.3.4 cm are often markers in favour of more significant TR. The

normal motion and contraction of the tricuspid annulus also con-

tributes to maintaining valve competence. The normal contraction

(decrease in annular area in systole) of the tricuspid annulus is

25%. These reference measures are currently used to propose tri-

cuspid valve repair at the time of left-sided valve surgery.

However, as the shape of the tricuspid annulus is not circular but

oval, with a minor and a major diameter, the 2D echo measurement

of the tricuspid annulus diameters (apical four-chamber view, para-

sternal short-axis view) systematically underestimate the actual tri-

cuspid annulus size by 3D echo. As a consequence, 65% of patients

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Table 3 Grading the severity of organic mitral regurgitation

Parameters Mild Moderate Severe

Qualitative

MV morphology Normal/Abnormal Normal/Abnormal Flail lefleat/Ruptured PMs

Colour flow MR jet Small, central Intermediate Very large central jet or eccentric jet adhering,

swirling and reaching the posterior wall of the LAFlow convergence zonea No or small Intermediate Large

CW signal of MR jet Faint/Parabolic Dense/Parabolic Dense/Triangular

Semi-quantitative

VC width (mm) ,3 Intermediate 7 (.8 for biplane)b

Pulmonary vein flow Systolic dominance Systolic blunting Systolic flow reversalc

Mitral inflow A wave dominantd Variable E wave dominant (.1.5 cm/s)e

TVI mit /TVI Ao ,1 Intermediate .1.4

Quantitative

EROA (mm2) ,20 20 29; 30 39f 40

R Vol (mL) ,30 30 44; 45 59f 60

+ LV and LA size and the systolic pulmonary pressureg

CW, continuous-wave; LA, left atrium; EROA, effective regurgitant orifice area; LV, left ventricle; MR, mitral regurgitation; R Vol, regurgitant volume; VC, vena contracta.aAt a Nyquist limit of 5060 cm/sbFor average between apical four- and two-chamber views.cUnless other reasons of systolic blunting (atrial fibrillation, elevated LA pressure).dUsually after 50 years of age;ein the absence of other causes of elevated LA pressure and of mitral stenosis.fGrading of severity of organic MR classifies regurgitation as mild, moderate or severe, and sub-classifies the moderate regurgitation group into mild-to-moderate (EROA of

2029 mm or a R Vol of 3044 mL) and moderate-to-severe (EROA of 3039 mm 2 or a R Vol of 4559 mL).gUnless for other reasons, the LA and LV size and the pulmonary pressure are usually normal in patients with mild MR. In acute severe MR, the pulmonary pressures are usually

elevated while the LV size is still often normal. In chronic severe MR, the LV is classically dilated. Accepted cut-off values for non significant left-sided chambers enlargement: LA

volume ,36 mL/m2, LV end-diastolic diameter,56 mm, LV end-diastolic volume ,82 mL/m2, LV end-systolic diameter,40 mm, LV end-systolic volume ,30 mL/m2, LA

diameter,39 mm, LA volume ,29 mL/m2.



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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Table 4 Echocardiographic parameters used to quantify mitral regurgitation severity: recordings, advantages and

limitations

Parameters Recordings Usefulness/advantages Limitations

Mitral valve

morphology Visual assessment

Multiple views

Flail valve or ruptured PMs are

specific for significant MR

Other abnormalities are non-specific of

significant MR

Colour flow MR jet Optimize colour gain/scale

Evaluate in two views

Need blood pressure evaluation

Ease of use

Evaluates the spatial

orientation of MR jet

Good screening test for mild

vs. severe MR

Can be inaccurate for estimation of MR

severity

Influenced by technical and

haemodynamic factors

Underestimates eccentric jet adhering

the LA wall (Coanda effect)

VC width Two orthogonal planes (PT-LAX, AP-4CV)

Optimize colour gain/scale

Identify the three components of the

regurgitant jet (VC, PISA, Jet into LA)

Reduce the colour sector size and imaging

depth to maximize frame rate

Expand the selected zone (Zoom) Use the cine-loop to find the best frame for

measurement

Measure the smallest VC (immediately distal

to the regurgitant orifice, perpendicular to

the direction of the jet)

Relatively quick and easy

Relatively independent of

haemodynamic and

instrumentation factors

Not affected by other valve

leak

Good for extremes MR: mildvs. severe

Can be used in eccentric jet

Not valid for multiple jets

Small values; small measurement errors

leads to large % error

Intermediate values need confirmation

Affected by systolic changes in

regurgitant flow

PISA method Apical four-chamber

Optimize colour flow imaging of MR

Zoom the image of the regurgitant mitral

valve

Decrease the Nyquist limit (colour flow zero

baseline)

With the cine mode select the best PISA

Display the colour off and on to visualize the

MR orifice Measure the PISA radius at mid-systole using

the first aliasing and along the direction of the

ultrasound beam

Measure MR peak velocity and TVI (CW)

Calculate flow rate, EROA, R Vol

Can be used in eccentric jet

Not affected by the aetiology

of MR or other valve leak

Quantitative: estimate lesion

severity (EROA) and volume

overload (R Vol)

Flow convergence at 50 cm/s

alerts to significant MR

PISA shape affected

by the aliasing v elocity

in case of non-circular orifice

by systolic changes in regurgitant

flow

by adjacent structures (flow

constrainment)

PISA is more a hemi-ellipse

Errors in PISA radius measurement are

squared

Inter-observer variability

Not valid for multiple jets

Doppler

volumetric method

(PW)

Flow across the mitral valve Measure the mitral inflow by placing the PW

sample volume at the mitral annulus

(AP-4CV)

Measure the mitral annulus diameter

(AP-4CV) at the maximal opening of the

mitral valve (two to three frames after the

end-systole).

Flow across the aortic valve

Measure the LV outflow tract flow by placing

the PW sample volume 5 mm below the

aortic cusps (AP-5CV)

Measure the LV outflow tract diameter

(parasternal long-axis view)

Quantitative: estimate lesion

severity (ERO) and volume

overload (R Vol)

Valid in multiple jets

Time consuming

Requires multiple measurements: source

of errors

Not applicable in case of significant AR

(use the pulmonic site)

Difficulties in assessing mitral annulus

diameter and mitral inflow in case of

calcific mitral valve/annulus

Affected by sample volume location

(mitral inflow)

Continued



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with normal tricuspid annulus diameter at 2D echo show grade 1 2

TR compared with 30% of patients with normal tricuspid annulus

size at 3D echo.47,48 Conversely, calculation of tricuspid annulus

fractional shortening yields the same results using 2D echo and

3D echo since the extent of underestimation of tricuspid annulus

diameter made by 2DE is comparable in diastole and in systole.

Three papillary muscle groups (anterior, posterior, and septal)

usually support the TV leaflets and lie beneath each of the three

commissures. The papillary muscles exhibit variability in size. The

anterior and septal papillary muscles are the largest. The posterior

papillary muscle is small and, at times, absent. The anterior papil-

lary muscle has attachments to the moderator band. Each leaflet

has chordal attachments to one or more papillary muscles.

Aetiology and mechanismsSmall physiologic degrees of TR are frequently encountered in

the normal disease-free individual. The prevalence could reach

6575%.49 On echocardiography, this physiological TR is associ-

ated with normal valve leaflets and no dilatation of the RV. It islocalized in a small region adjacent to valve closure (,1 cm),

with a thin central jet and often does not extend throughout

systole. Peak systolic velocities are between 1.7 and 2.3 m/s.

In the pathologic situation, a complete understanding of leaflet

morphology and of the pathophysiological mechanisms underlying

TR could potentially lead to improved techniques for valve repair

and to design physiologically suitable annular rings. It should be

stressed that TR is most often seen in patients with multiple valv-

ular disease especially aortic or mitral valve disease. The most

common cause of TR is not a primary tricuspid valve disease

(organic TR) but rather an impaired valve coaptation (secondary

or functional TR) caused by dilation of the RV and/or of the

tricuspid annulus. A variety of primary disease processes can

affect the tricuspid valve complex directly and lead to valve incom-

petence: infective endocarditis, congenital disease like Ebstein

anomaly or atrioventricular canal, rheumatic fever, carcinoid syn-

drome, endomyocardial fibrosis, myxomatous degeneration of

the tricuspid valve leading to prolapse, penetrating and non-

penetrating trauma, and iatrogenic damages during cardiac

surgery, biopsies, and catheter placement in right heart chambers.

Aetiology

Degenerative tricuspid regurgitation

As for MR, three types of tricuspid changes can be visualized: a bil-

lowing valve, a prolapsing valve and a flail tricuspid valve. Tricuspid

prolapse is generally associated with mitral valve prolapse and is

defined as a mid-systole posterior leaflet displacement beyond the

annular plane. The coaptation line is behind the annular plane. Tri-

cuspid prolapse most often involves theseptal and anterior tricuspid

leaflets. The most common phenotype of tricuspid prolapse is

diffuse myxomatous degeneration (Barlows disease). A flail tricus-

pid leaflet is observed when the free edge of a leaflet is completelyreversed in the RA, usually as a consequence of ruptured chordae

(degenerative TR, infective endocarditis, trauma).

Rheumatic tricuspid regurgitation

Rheumatic involvement of the tricuspid valve is less common than

that of left-sided valves. Regurgitation is a consequence of deform-

ity, shortening and retraction of one or more leaflets of the tricus-

pid valve as well as shortening and fusion of the chordae tendineae

and papillary muscles. 2D echo usually detects thickening and the

distortion of the leaflets but cannot provide a comprehensive

assessment of extension of valve apparatus involvement. The 3D

full-volume data set from apical approach usually provides a

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Table 4 Continued

Parameters Recordings Usefulness/advantages Limitations

CW MR jet profile Apical four-chamber Simple, easily available Qualitative, Complementary finding

Complete signal difficult to obtain in

eccentric jet

Pulmonary vein

flow Apical four-chamber

Sample volume of PW places into the

pulmonary vein

Interrogate the different pulmonary veins

when possible

Simple

Systolic flow reversal is specific

for severe MR

Affected by LA pressure, atrial

fibrillation

Not accurate if MR jet directed into

sampled vein

Peak E velocity Apical four-chamber

Sample volume of PW places at mitral leaflet

tips

Simple, easily available

Dominant A-wave almost

excludes severe MR

Affected by LA pressure, atrial

fibrillation, LV relaxation

Complementary finding

Atrial and LV size Use preferably the Simpson method Dilatation sensitive for chronic

significant MR

Normal size almost excludes

significant chronic MR

Dilatation observed in other conditions

(non specific)

May be normal in acute severe MR

CW, continuous-wave; LA, left atrium, EROA, effective regurgitant orifice area; LV, left ventricle; MR, mitral regurgitation; PW, pulse wave; R Vol, regurgitant volume; VC, vena

contracta.



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comprehensive assessment of the whole tricuspid valve apparatus

which can be examined from different perspectives. The en face

view of the tricuspid valve obtained by 3D echo allows the visual-

ization of the commissural fusion.

Functional tricuspid regurgitation

Functional TR results from the adverse effects on RV function and

geometry caused by left-sided heart valve diseases, pulmonary

hypertension, congenital heart defects, and cardiomyopathy. Theprogressive remodelling of the RV volume leads to tricuspid

annular dilatation, papillary muscle displacement and tethering of

the leaflets, resulting in TR. TR itself leads to further RV dilation

and dysfunction, more tricuspid annular dilatation and tethering,

and worsening TR. With increasing TR the RV dilates and eventually

fails, causing increased RV diastolic pressure and, in advanced situ-

ationsa shift of theinterventricularseptum towardthe LV. Such ven-

tricular interdependence might reduce the LV cavity size (pure

compression), causing restricted LV filling and increased LV diastolic

and pulmonary artery pressure. The tricuspid annular dilatation, the

lost of its contraction and the increased tethering are probably the

most important factors in the development of TR. Indeed, the

tricuspid annulus is not saddle-shaped anymore; it becomes flat,

planar, and distorted. Increased tethering (apical displacement of

the tricuspid leaflets) can be evaluated by the measurement of the

systolic tenting area (area between the tricuspid annulus and the tri-

cuspid leaflets body) and the coaptation distance (distance between

the tricuspid annular plane and the point of coaptation) in mid-

systole from the apical four-chamber view. A tenting area .1 cm2

has been shown to be associated with severe TR.50

Carcinoid tricuspid regurgitation

In the carcinoid disease, the valve appears thickened, fibrotic with

markedly restricted motion during cardiac cycle. Both 2D/3D echo

can show the regions of ineffective leaflet coaptation and the lack

of commissural fusion.

Mechanism

In recent years, repair techniques for diseased tricuspid valves

have evolved. Precise determination of the mechanisms of TR

has thus become an essential component of the echocardio-

graphic examination (Figure 27). The Carpentiers classification

remains the most common used functional classification: type I:

Figure 26 2D and 3D echo recordings of the tricuspid valve. (A) Parasternal long-axis view; (B) parasternal short-axis view at the level of theaortic valve; (C) apical four-chamber view; (D) sub-costal view. A, anterior leaflet; S, septal leaflet; P, posterior leaflet.



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leaflet perforation (infective endocarditis) or more frequently by

annular dilatation; type II: prolapse of one or more leaflets (tri-

cuspid valve prolapse); and type III: restricted motion as the con-

sequence of rheumatic disease, significant calcifications, toxic

valvulopathy, functional TR.

Persistent or recurrent TR has been reported in up to 2050%of patients undergoing mitral valve surgery.51 In functional TR, this

has been related to the extent of tricuspid leaflet restriction and to

the severity of tricuspid annular dilatation. Both the severity of pre-

operative TR and RV dysfunction contributes to residual post-

operative TR. Similarly, severe tricuspid valve tethering predicts

residual TR after tricuspid valve annuloplasty. A tenting area

.1.63 cm2 and a tethering distance .0.76 cm are good predictors

of residual TR after tricuspid valve surgery.52

Key point

In the presence of TR, tricuspid valve analysis is manda-

tory. 2D-TTE imaging is the technique of choice. 3D-TTE

can be used as an additive approach. TEE is advised in caseof suboptimal TTE images. Distinction between primary

and secondary TR is warranted.

Assessment of tricuspid regurgitationseverityColour flow Doppler

Grading the severity of TR is in principle similar to MR. However,

because standards for determining the TR severity are less robust

than for MR, the algorithms for relating colour flow derived par-

ameters to TR severity are less well developed.

Colour flow imaging

Colour-flow imaging is useful to recognize small jets, but the

assessment of larger TR jets has important limitations.53 Indeed,

flow jets that are directed centrally into the RA generally appear

larger than eccentric wall-impinging jets with similar or worse

severity. Basically, multiple windows (apical four-chamber, para-sternal long and short axis views, sub-costal view) are rec-

ommended to assess TR severity by colour-flow analysis

(Figure 28). The general assumption is that larger colour jets that

extend deep into the RA represent more TR than small thin jets

that appear just beyond the tricuspid leaflets. As for MR, this

method is a source of many errors and is limited by several tech-

nical and haemodynamic factors. Furthermore, it is not rec-

ommended to assess TR severity. Nevertheless, the detection of

a large eccentric jet adhering, swirling and reaching the posterior

wall of the RA is in favour of significant TR. Conversely, small

thin central jets usually indicate mild TR.

Key pointThe colour flow area of the regurgitant jet is not rec-

ommended to quantify the severity of TR. The colour

flow imaging should only be used for diagnosing TR. A

more quantitative approach is required when more than

a small central TR jet is observed.

Vena contracta width

The vena contracta of the TR is typically imaged in the apical

four-chamber view using the same settings as for MR (Figure 29).

Averaging measurements over at least two to three beats is

recommended. A vena contracta 7 mm is in favour of severe TR

although a diameter ,6 mm is a strong argument in favour of

Figure 27 Mechanisms of mitral regurgitation according to the Capentiers functional classification.



20/26

mild or moderate TR.54 Intermediate values are not accurate at dis-

tinguishing moderatefrom mild TR. As for MR, the regurgitant orifice

geometry is complex and not necessarily circular. A poorcorrelation

has been suggested between the2D venacontractawidthand the3D

assessment of the EROA. This could underline the poor accuracy of

the 2D vena contracta width in eccentric jets. With 3D echo, an

EROA. 75 mm2 seems to indicate severe TR.55 However, these

data need to be confirmed in further studies.

Key point

When feasible, the measurement of the vena contracta

is recommended to quantify TR. A vena contracta width

7 mm defines severe TR. Lower values are difficult tointerpret. In case of multiple jets, the respective values

of the vena contracta width are not additive. The assess-

ment of the vena contracta by 3D echo is still reserved

to research purposes.

The flow convergence method

Although providing quantitative assessment, clinical practice revealsthat the flow convergence method is rarely applied in TR. This

approach has been validated in small studies.5658 The apical four-

chamber view and the parasternal long and short axis views are clas-

sically recommended for optimal visualization of the PISA. The area

of interest is optimized by lowering imaging depth and the Nyquist

limit to 1540 cm/s. The radius of the PISA is measured at mid-

systole using the first aliasing (Figure 30). Qualitatively, a TR PISA

radius .9 mm at a Nyquist limit of 28 cm/s alerts to the presence

of significant TR whereas a radius ,5 mm suggests mild TR.57 An

EROA 40 mm2 or a R Vol of 45 mL indicates severe TR. As

mentioned in the first part of the recommendations on the assess-

ment of valvular regurgitation, the PISA method faces several advan-

tages and limitations.1 It could underestimate the severity of TR by

30%. This method is also less accurate in eccentric jets. To note, the

number of studies having evaluated the value of the flow conver-

gence method in TR are still limited.

Key point

When feasible, the PISA method is reasonable to

quantify the TR severity. An EROA 40 mm2 o r a R Vol 45 mL indicates severe TR.

Pulsed Doppler

Doppler volumetric method

Quantitative PW Doppler method is rarely used to quantify the TR

severity. As for MR, this approach is time consuming and is associ-ated with several drawbacks (see above).

Anterograde velocity of tricuspid inflow

Similar to MR, the severity of TR will affect the early tricuspid dias-

tolic filling (E velocity). In the absence of tricuspid stenosis, the peak

E velocity increases in proportion to the degree of TR. Tricuspid

inflow Doppler tracings are obtained at the tricuspid leaflet tips. A

peak E velocity 1 m/s suggests severe TR (Figure 31).

Hepatic vein flow

Pulsed Doppler evaluation of hepatic venous flow pattern is

another aid for grading TR. In normal individuals, the patternof flow velocity consists of antegrade systolic, transient flow

reversal as the TV annulus recoils at the end of systole, ante-

grade diastolic and a retrograde A wave caused by atrial contrac-

tion. Such hepatic flow patterns are affected by respiration. With

increasing severity of TR, there is a decrease in hepatic vein sys-

tolic velocity. In severe TR, systolic flow reversal occurs

(Figure 32). The sensitivity of flow reversal for severe TR is

80%.53 Thus, the absence of systolic flow reversal does not

rule out severe TR. Blunted systolic hepatic vein flow can be

observed in case of abnormal right atrial and RV compliance,

atrial fibrillation and elevated right atrial pressure from any

cause.59 Blunting of hepatic flow may thus lack of specificity.

Figure 28 Visual assessment of tricuspid regurgitant jet using

colour-flow imaging. (A) Large central jet; (B) eccentric jet with

a clear Coanda effect. CV, four-chamber view.

Figure 29 Semi-quantitative assessment of tricuspid regurgita-

tion severity using the vena contracta width (VC). The three

components of the regurgitant jet (flow convergence zone,

vena contracta, jet turbulence) are obtained. CV, chamber view.



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Retrograde systolic flow can also be seen with colour flow

Doppler. It can be associated with phasic spontaneous appear-

ance of some contrast in the hepatic vein.

Key point

The systolic hepatic flow reversal is specific for severe

TR. It represents the strongest additional parameter for

evaluating the severity of TR.

Continuous wave Doppler of tricuspid regurgitation jet

Signal intensity and shape

As for MR, the CW envelope of the TR jet can be a guide to TR

severity. A dense TR signal with a full envelope indicates more

severe TR than a faint signal. The CW Doppler envelope may be

truncated (notch) with a triangular contour and an early peak vel-ocity (blunt). This indicates elevated right atrial pressure or a pro-

minent regurgitant pressure wave in the RA due to severe TR.

Marked respiratory variation (decreased TR velocity with inspi-

ration) suggests an elevated RA pressure (Kussmauls sign on phys-

ical examination).

Pulmonary artery pressure

The TR jet can be used to determine RV or pulmonary artery sys-

tolic pressure. This is done by calculating the RV to RA pressure

gradient using the modified Bernoulli equation and then adding

an assumed RA pressure. Details on how to assess pulmonary

pressure will be provided in other recommendations. To note,

the velocity of the TR jet by itself does not provide useful infor-

mation about the severity of TR. For instance, massive TR is

often associated with a low jet velocity (,2 m/s) as there is

near equalization of RV and RA pressures.60 In some case, a high-

velocity jet that represents only mild TR may be present when

severe pulmonary hypertension is present.

Consequences of tricuspid regurgitationSigns of severe TR include RA and RV dilatation, a dilated and pul-

satile inferior vena cava and hepatic vein, a dilated coronary sinus

and systolic bowing of the interatrial septum toward the LA. Evi-

dence of right heart dilatation is not specific for TR but can be

noted in other conditions (pulmonary valve regurgitation,

left-to-right atrial shunt, anomalous venous return). However, itsabsence suggests milder degree of TR. Imaging the vena cava and

its respiratory variation also provides an evaluation of RA pressure.

Although not specific, a rapid anterior motion of the interventicu-

lar septum at the onset of systole (isovolumic contraction; para-

doxical ventricular septal motion) represents a qualitative sign of

RV volume overload due to severe TR.

Right ventricle size and function

Similar to LV, the RV dimensions and ejection fraction reflect the

right hearts ability to adapt to increased volume load. In case of

TR, significant changes in RV shape can occur. An end-systolic

RV eccentricity index greater than twoobtained by dividing the

Figure 30 Quantitative assessment of TR severity using the proximal isovelocity surface area (PISA) method. Stepwise analysis of mitral

regurgitation: (A) Apical four-chamber view (CV); (B) colour-flow display; (C) zoom of the selected zone; (D) downward shift of zero baseline

to obtain an hemispheric PISA; (E) measure of the PISA radius using the first aliasing; ( F) continuous wave Doppler of tricuspid regurgitation

jet allowing calculation the effective regurgitant orifice area (EROA) and regurgitant volume (R Vol). TVI, time-velocity integra

eje2010_eco en valvulopatia mitral y tricuspide

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